Radiologists are not doctors reading images. They are physicians who perform and interpret tests (X-rays, ultrasound, CT scan, MRI, PET/CT) and intervene in the body (biopsies and other treatments) and help the treating physicians manage their patients better.

This is why teleradiology is so intellectually stultifying, because it commoditizes the radiologist and converts him/her into a "reading machine", taking away the "physician" part of being a radiologist.

This blog is all about those stories that make it gratifying being a radiologist.

And some thoughts about radiology.

If you have stories to share, feel free to email me on bhavin at jankharia dot com

Comprehensive health check-ups have become all the rage. There is a general feeling that doing a non-targeted check-up once a year helps pick up disease early and prevent future problems.

For corporate chains, health check-ups have become big businesses to the extent that many chains have actually opened out-patient health check-up centres that include “5-star” facilities that we otherwise find only in spas and high-end beauty salons.

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As everyone working in this field knows, the prognosis of idiopathic pulmonary fibrosis (IPF) is quite dismal (3 years survival of 50%). There have been many treatment regimens that have been suggested, but it is not clear whether any of them are of any use.

There is a lovely short commentary / editorial that puts all these papers in perspective and even addresses the question of whether both nintedanib and pirfenidone should be used together and whether that would help even more or not. This is an interesting thought.

All of these are must reads for all those who have patients with IPF whose care they are responsible for.

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There is an amazing amount of focus in the cardiology literature on the issue of contrast-induced nephropathy (CIN) with intra-arterially injected iodinated contrast media.

This week’s issue of JACC (Journal of American College of Cardiology) has two articles on the use of statins (in this case, specifically, rosuvastatin) that reduces the risk of CIN in high-risk patients undergoing catheter coronary angiography. The first article by Han et al has a larger group of patients who are diabetic and have mild to moderate CKD whereas the second article by Lencioni M et al has a smaller group of patients who presented predominantly with non-ST segment acute coronary syndrome.

In both articles, the patients were well-hydrated. Both have a control group that did not receive statins and both articles unequivocally show a reduction in the incidence of CIN.

Whether this is applicable to patients undergoing contrast administration during computed tomography is uncertain.

The overall incidence of CIN in practice is low and if we stick to the basic principles of evaluating the renal function in those at risk and using hydration and low-ionic contrast media, we can pretty much reduce the risk considerably. It is a good idea to re-evaluate all of this by going through the 2013 edition of the ACR criteria and a lovely review article by a Jorgensen Ann, a nurse. Many of us also use acetyl-cysteine, but the data regarding its efficacy is not very robust.

As usual, if you need copies of the JACC articles for personal perusal, send me a request.

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These are the kind of studies we need more off. Clearly, when the same was done for vertebroplasty versus sham, it raised the hackles of everyone in the radiology world, because two independent studies showed that vertebroplasty was no better than a sham procedure. Of course that controversy in no way seems to have dampened the use of vertebroplasty.

This week’s NEJM has an article that discusses the value of arthroscopic surgery for meniscal degeneration in patients with osteoarthritis and finds the results no better than sham surgery. We already know this intuitively and from anecdotal experience and this is one of the reasons not to overcall meniscal degeneration as tears to prevent unnecessary arthroscopic exploration of frankly osteoarthritic knees.

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This article by Lee T H in the recent issue of the NEJM actually discusses “the word that shall not be spoken”, i.e. “suffering”. What is even more interesting is that he describes this in the context of a healthcare company’s business strategy – to reduce suffering from disease, from complications and from dysfunction of the delivery system.

And yet, by word of mouth, it has always been possible to know of surgeons who are “amazing”, “lightning fast” and “gifted”. The anesthetists, nurses and resident surgeons are in the best possible position to compare and evaluate, along with the surgical ICU doctors. This knowledge obviously rarely gets passed on to patients.

It is the same in radiology. All radiologists are not and can never be the same, which is why radiology cannot be commoditized or “teleradiologized”. And over a period of time, everyone in the community knows who the brilliant ones are, both from a diagnostic as well as an interventional perspective. The patients may never come to know.

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This is the kind of article that should be completely free, but is unfortunately behind a paywall . This article by Dhanoa D et al in the J of the American College of Radiology tracks the typical workday or hospital radiologists in 3 hospitals in British Columbia in Canada and not surprisingly comes up with final conclusion, though they don’t use these words per se, “radiologists are not image-readers – they are physicians who are actively involved in patient management using tools of image interpretation and intervention”.

For those of you who want a copy, email me or leave a comment with your email ID and I will send you the article.

The take-home points are:

Local on-site radiologists spend 36.4% of their clinical time on image interpretation.

43.8% of on-site radiologists’ clinical time is spent on noninterpretative activities, such as quality assurance tasks, patient safety responsibilities, and image-guided procedures.

The total clinical productivity of on-site radiologists is 87.7%.

On-site radiologists experience an average of 6 inter- actions per hour with health care personnel, of which 81.2% directly influence patient care in the medical imaging department.

Replacing the on-site radiologist discounts the value of their noninterpretative activities, suggesting a loss to the provision of high-quality patient care.

Essentially, an on-site radiologist is critical to patient management.

This would even translate to diagnostic centers, where even though there is reduced direct interaction with treating physicans and surgeons, the amount of time spent on the phone or other methods of communication interacting with referring doctors with respect to appointments, scheduling the correct study for the correct clinical situation, monitoring studies, contacting the doctors with provisional and final reports and ensuring proper patient flow, as well as dealing directly with patient queries, etc. takes up a significant amount of time. At best, even in an optimized private practice workflow situation, a radiologist is unlikely to spend more than 50% of his/her time actively looking at images.

Three criteria are important – microcalcifications, completely solid appearance and size greater than 2 cm. If we stringently follow the rule that at least two of these criteria have to be present before performing thyroid nodule biopsy, then the sensitivity would be reduced but with a high positive predictive value, but without compromising the ability to pick up malignancy. It is worth reading the article to understand the importance of large population based studies to help us use our radiology signs to better triage patients.